Bronchial stump aspergillosis. An unusual disease

Briz, Elena; Sander, Rolf; Gómez González, Carlos; Borderías, Luis

doi:10.1016/j.medcle.2016.05.037

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Una entidad inusual" ] ] "textoCompleto" => "Aspergillus can cause a wide range of respiratory diseases depending on the fungus-host interaction, where the immune status of the subject plays an important role.<a class="elsevierStyleCrossRef" href="#bib0055">1</a> In very few cases have we seen an initially saprophytic case of patients after a lung resection, that affects the tissue granulation in the area of the suture and is called bronchial stump aspergillosis. Symptoms consist of coughing with mucous expectoration, sometimes haemoptysis, and dyspnea,<a class="elsevierStyleCrossRefs" href="#bib0060">2–5</a> and the differential diagnosis includes, among others, lung tumours, and other processes caused by Aspergillus.<a class="elsevierStyleCrossRefs" href="#bib0080">6–10</a>We report the case of a 61-year-old woman with no toxic habits and a history of right pneumonectomy after suffering a car accident in 1978. She was referred because of paroxysms of coughing and low mucous expectoration, general malaise, and dyspnoea which she related to her cough lasting approximately 8 weeks. These symptoms did not improve after administration of oral corticosteroids, bronchodilators, oral N-acetylcysteine and antibiotics. On examination there were no abnormalities except decreased a vesicular breath sound in the right chest, and the tests showed an ESR of 60mmHg in the first hour, a concentration of IgE serum of 756KU/l, Aspergillus IgE RAST 3.50KU/l and an undetectable determination of Aspergillus precipitins. The other usual analytical tests, including other immunoglobulins, IgG and immunity subfractions, were normal. Chest radiograph and CT showed the sequelae of pneumonectomy, but there were no images of bronchiectasis, cavities or blisters, mucus plugs or atelectasis. The skin prick test for Aspergillus was negative and the spirometry ruled out bronchial obstruction.Aspergillus fumigatus grew in sputum studies (with CMI voriconazole at 0.5μg/ml) and the sputum cytology showed signs of acute inflammation without eosinophils or neoplastic cells. The fibrobronchoscopy showed a necrotic mass that had a spherical morphology and seemed pearl shaped in the bronchial stump that was aspirated, and the underlying mucosa showed mild inflammation, without evidence of bleeding or other alterations. A histological examination and culture confirmed the presence of Aspergillus. The patient rejected an endoscopic removal of the suture and treatment with antifungals.Followed in outpatients, the patient has remained asymptomatic and sputum tests have not been able to again isolate Aspergillus nor detect the presence of eosinophils in sputum and/or peripheral blood. The IgE RAST was normalised at 5 months (<0.35KU/l), without modification to date, the total IgE has decreased (255KU/l) and Aspergillus IgG precipitins have increased (126mg/l), with negative skin tests persisting.Aspergillosis of the bronchial stump is uncommon, and although it has been described with metallic suture materials and nylon,<a class="elsevierStyleCrossRefs" href="#bib0080">6,7</a> it more frequently occurs with the use of silk, as it did in this patient, because of their high capillarity and plurifilamentous nature, which triggers a local inflammatory process and encourages the colonisation of Aspergillus.<a class="elsevierStyleCrossRef" href="#bib0070">4</a> Most patients are immunocompetent and the latency period is variable; in this patient it was 32 years, which is the highest reported in the literature.In the few cases where serological tests are conducted they have been described as negative.<a class="elsevierStyleCrossRefs" href="#bib0085">7,8</a> In this case there was no asthma or eosinophilic inflammation, the skin prick test was negative, the values of IgE RAST, usually lower than those found in asthma or ABPA, and spirometry and monitoring of the peak expiratory flow showed no fall in FEV1 and PEF. At follow-up, IgE RAST figures were normalised, raising the number of precipitin, which shows a modification of the immune response after removal of aspergilloma from the stump, without any other clinical form such as mycetoma, asthma or pneumonitis by hypersensitivity coexisting.The treatment of choice is the removal of the suture material by endoscopy, and if this is not possible or symptoms persist, treatment with sensitive antifungals such as voriconazole should be initiated.<a class="elsevierStyleCrossRefs" href="#bib0095">9,10</a> The patient rejected both treatments. Unlike the rest of the reported cases, simply removing the aspergillosis necrotic mass was sufficient, and 5 years later the patient remains asymptomatic. This fact may have influenced the reason why the pneumonectomy was conducted as, unlike the other patients in the literature, it was due to a trauma and not tuberculosis or bronchopulmonary neoplasia. This treatment has not proven effective in other cases, relapses may occur,<a class="elsevierStyleCrossRef" href="#bib0085">7</a> so that the patient has been indicated that at the onset of cough, haemoptysis, or dyspnoea a possible relapse should be ruled out. Despite its infrequency, this process should be considered when presented with patients with lung resections and persistent cough and/or chronic or self-limiting haemoptysis." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Briz E, Sander R, Gómez González C, Borderías L. Aspergilosis del muñón bronquial. Una entidad inusual. Med Clin (Barc). 2016;146:330–331." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary aspergillosis: a clinical review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Kousha" 1 => "R. Tadi" 2 => "A.O. 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ISSN: 2387-0206

Launched in 1943, Medicina Clínica is a fortnightly journal aimed at the promotion of clinical research and practice among internal medicine and other specialists. The key characteristics of Medicina Clínica are the scientific and methodological rigor of its manuscripts, the topicality of its contents, and, especially, its practical focus with highly useful information for clinical practice. Medicina Clínica is predominantly interested in publishing original research manuscripts, which are rigorously selected according to their quality, originality, and interest, and also in continued medical education-oriented manuscripts, which are commissioned by the journal to relevant authors (Editorials, Reviews, and Diagnosis and Treatment). These manuscripts contain updated topics with a major clinical or conceptual relevance in modern medicine. The journal adheres to the standards of academic research publications in all aspects including peer-review and ethical principles. Medicina Clínica is included in the General and Internal Medicine category of Thomson Reuters.

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Current Contents/Clinical Medicine, Journal Citation Reports, SCI-Expanded, Index Medicus/Medline, Excerpta Medica/EMBASE, IBECS, IME, MEDES, PASCAL, SCOPUS, SciVerse ScienceDirect

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Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

© Clarivate Analytics, Journal Citation Reports 2022

Impact factor 2023

2.6

Citescore

CiteScore measures average citations received per document published.

Citescore 2023

3.1

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.371

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

0.511

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Journal Information

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Vol. 146. Issue 7.

Pages 330-331 (April 2016)

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